PT-0085-2019 Office Use Only
Permit#: Pi —(P S� l
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742 Bay Road,Queensbury,NY 12804 Fee: �5 be-)
P:518-761-8206 or 518-761-8205 www.queensbury.net
Invoice#: z
SEWAGE DISPOSAL SYSTEM INSPECTION INFORMATION
Individual Residential Wastewater Treatment System
Property and Owner
//Information: (Please attach property survey or tax parcel map)
Property address: `b J B _boo Lit—1151
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Tax map number:
Property owner: /-rnd( 517O k(ilex 6/—
Mailing Address (c/s/z): t-1 ,L ol-r;„,„(1 ✓1 APi- 3 c,-.rCAfc)g,./V is 8-66
Cell#: 5-1,5S>" ?766- _ Land Line#:
Email: S t ro )-, it-t Y 2r 0-r-\ CZ 5 v„o_;I .c o N1
Household Information:
#Bedrooms #Bathrooms \ #Kitchens
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: Tank Size of Septic Tank ( CJ (e) n
Type of Absorption System:
Are all system components wholly within the property boundaries? f/ Yes No
Are system plans available'? _Yes No
Does the system(s)serve multiple properties? Yes No
If yes, describe
Maintenance:
Service agreement'? Yes No yes, vendor name
Date of last inspection N/A Date tank last pumped N/A t/
Frequency of pumping N/A
Property Transfer Packet Revised February 2019
=z 4eGi.i_r_pq'$.ferseikao'pisposal' Information Form
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FEB 2 0 2019 u
742 Bay Road,Queensbury,NY 12804 ---�
P:518-761-8256 www.queensbury.net TOVVN ®F QUEEN BURY
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To: Ad(et--) (d M.e e
(Name of Applicant)
Re: Onsite Wastewater Treatment Sys em Inspection Information Request for:
9,6 13 �dcc 9.a q n51bWIy y
(Site Add rss)
Thank you for requesting an inspection for the onsite wastewater treatment system located on the property
referenced above. We look forward to completing a thorough inspection for you. You can help us do the best
job possible by providing some advance information to us about the site. Prior to our inspection, we request
information regarding the property and the onsite wastewater treatment system (septic system) on that
property. We also would like to confirm property access and that pre-inspection system preparation will be
completed prior to our arrival.
Enclosed is a Septic System Inspection Information form, which must be completed, signed and returned to
this office prior to scheduling an inspection. Following completion of the inspection,you will be sent a System
Inspection Site Report. The System Inspection Information Request and the System Inspection Site Report are
standardized forms used by the Town of Queensbury.
Please note the Town of Queensbury's fee for this service is $250. Be advised that all fees for services must be
paid prior to the site inspection. We require 48 hours notification prior to inspections. If you have any
questions, please call. You may FAX or email the completed Septic System Inspection Information form back
to us.
Phone: (518) 761-8256 Fax: (518) 745-4437 Email: kated@queensbury.net
Thank you.
Sincerely,
( A1P 4 10t.
David Hatin, Director
Building and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised February 2019
List known repairs/replacements,with dates:
Date Type of Repair/Replacement
Operation:
• System problems? Yes No
• Sewage odors? Yes No
Direct surface discharge(s)? Yes ? No
• Back-up of toilets? Yes )o No
Back-up of any other fixtures? (e.g. slow drains) Yes )e No
• Seasonal ponding or breakout of leach field? Yes 1C No
Statement of Acceptance of Conditions:
I agree to:
• Ensure that the septic tank(s), distribution box(es), and/or seepage pit(s), if any,will be uncovered
prior to the requested inspection time;
• Have a septage hauler on site(to pump the tank after*the inspector verifies flow from fixtures);
➢ Tank must be pumped in presence of inspector
• Have an authorized representative present at the site;
• Allow the inspector to verify information provided above, and to conduct an inspection of the
indicated onsite wastewater treatment system(s), including all system components and interior
plumbing in crawl spaces and basements.
To the best of my knowledge, the information provided above is accurate.
I agree to be responsible for inspection fee payment.
Signature of property owner or authorized agent
Please print name: 0 (}( J
Affiliation: owner agent
Signature: Date: d k t Gj
Prior to scheduling with the Town of Queensburv, you MUST:
1. Schedule a sewage hauler to be on site to pump tank while inspector is on site.
Hauler should arrive 30-45 minutes after scheduled time with the Town of Queensbury's
Code Enforcement Officer.
2. Expose inlet and outlet of septic tank, and/or pump station, expose d-box, expose
any seepage pit covers.
3. Excavate test hole in leach field if there is no d-box.
Property Transfer Packet Revised February 2019
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SEWAGE DISPOSAL SYSTEM INSPECTION SITE REPORT
742 Bay Road, Queensbury, NY 12804
P: 518-761-8256 www.queensbury.net
Date: 26 February 2019
To: Andrew Strohmeyer
(Applicant)
Re: System Inspection Site Report for:
263 Big Boom Rd, Queensbury, NY 12804
(Site Address)
As requested, I have made an inspection of the wastewater system components serving the property
referenced above. All system components have been found, and are noted in the System Inspections
Findings Worksheet.
Inspector’s observations:
System appears to have functioned adequately under past and present loading. There can be no
assurance or guarantee of future performance for any period of time. Numerous factors, such as household
water usage, leaking toilets, soil characteristics and seasonal ground water table fluctuation, as well as owner
failure to manage and maintain the system, will affect its performance.
Please see the attached System Inspection Findings Worksheet and System Sketch for inspection details.
Sincerely,
David Hatin, Director
Building & Code Enforcement
Town of Queensbury
Building & Code Enforcement January 2019